NSAID Warnings: Missed Opportunities for Integration?

IN 2007, THE AMERICAN HEART ASSOCIATION ISSUED a scientific statement warning of the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) for those at risk of, or who have, existing cardiovascular conditions.1 As one might imagine, this encompasses a large segment of the population. This warning made headline news and it progressed over several years to include over-the-counter NSAIDs and eventually included warnings for short-term prescription use as well. All NSAIDs now carry what’s known as a black box warning, the strongest of all FDA warnings reserved for drugs that pose a significant risk to the population. (See sidebar.)

The chiropractic profession took note since AHA’s statement focused on the use of NSAIDs for musculoskeletal pain, which represents a huge U.S. economic burden and thus desirable market share. But doctors of chiropractic (DCs) also noted the glaring absence of chiropractic being touted as a safer alternative to be considered prior to, or along with, the use of NSAIDs: “Musculoskeletal symptoms should be categorized as those that result from tendonitis/bursitis, those that result from degenerative joint problems (e.g., osteoarthritis) or those that result from inflammatory joint problems (e.g., rheumatoid arthritis). Initial treatment should focus on nonpharmacological approaches (e.g., physical therapy, heat/cold, orthotics).”1

While disappointing, and another example of exclusion in mainstream medicine, the AHA statement underscores that the health care community still doesn’t understand our value. We can’t proclaim to have done a great job of capitalizing on the opportunity this scientific statement presented us. How many chiropractors can say that they reached out to medical physicians and talked pointedly about the impact of manipulation on VAS scores in the research or used head-to-head studies featuring manipulation and NSAIDs to compare outcomes?
Why Little Has Changed

While the scientific statement was acknowledged within the health care community, it didn’t slow the rate of prescribing. Based on my conversations with MDs, there are some common themes to explain this:

1) The MDs didn’t have any clinical experience to support the findings in the scientific statement. Perhaps it’s simply that they were unaware of any such consequences because the patients sought treatment elsewhere or because the link between the drug and the event was not obvious.

2) The physicians had to weigh quality of life against risk. It wasn’t that the MDs were glaringly ignoring the warnings, but what are they to do with a patient who experiences chronic pain who has tried and failed all traditional options? What do they do with a patient halted by pain who just isn’t surgical or who failed surgery altogether?

3) The physicians were comfortable working around the warnings by informing patients of the risk and monitoring for any medication side effects. They reported polypharmacy approaches in particular with gastrointestinal (GI) side effects, such as adding on proton pump inhibitors.

This is their need, and it’s what DCs have failed to show we can meet. Chiropractic physicians did not educate MDs on how and when to use our services, the safety supporting our care and the efficacy proven in the literature. As a result, MDs have not gained any clinical experience with chiropractic treatments. Nine years after the scientific statement and the opportunities it presented us, very few MDs have a treatment rationale for back pain that places manipulation or chiropractic care at any point in their treatment algorithm.
The Opioid Epidemic

We now face a similar opportunity with opioids. They are far dirtier than NSAIDs, have serious addictive concerns and are linked to rising heroin use (i.e., it’s cheaper and easier to get than opioids) and, sadly, death. Here are some facts taken from the American Society of Addiction Medicines’ “Opioid Addiction, 2016 Facts and Figures”:

• “Drug overdose is the leading cause of accidental death in the United States, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014.”

• “In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.”

For comparison’s sake, only 98 million prescriptions were filled in 2012, according to the Alliance for the Rational Use of NSAIDs. This same alliance recommends, “Any NSAID should be used at the lowest effective dose for the shortest duration of time required for relief while taking into account patient-specific risk factors and clinical needs.”

The two most commonly used medications for back pain have serious safety concerns and, of course, aren’t addressing any root cause of pain. This is a source of frustration for the chiropractic profession, who is proven in the research to offer a highly effective treatment choice but still wages a long-running battle over public perception.

Using Research to Educate

One of my favorite studies is a large one, which looked at both acute and chronic pain, measuring VAS and disability outcomes. It found that patients receiving primarily manipulation had significant reductions in VAS scores within two weeks of care.2 This study also included medical management with a primary treatment of NSAIDs. The same level of pain reduction was not observed in this group until the 12-week marker.

It’s studies like these that can help educate physicians on other opportunities to manage back pain and that offer talking points that are not opinions but facts. Sharing these studies with MDs, using a patient-centered focus, will help bring to life what we already know: Patients whose pain reduces can start to move again. They can do exercises, they have hope, they aren’t fearful – they realize back pain is not a lifetime sentence. Can’t it be argued that by achieving these goals, we have a better-educated patient who is actively participating in his or her care and will also have less direct and indirect health care costs associated with recovery?

These and other benefits are talking points you can use with physicians in your community to help educate them on the benefits of your care. It will help with inclusion into integrated care, and it will help increase access to our services that many of these patients would otherwise lack or not even consider.

I can’t help but get excited that with a forward motion and inclusion of our care into integrated settings, we may see a rise in professional opportunities and support from other health care professions. In this uncertain and changing health care system of accountable care organizations and other similar models, this assimilation is critical to survival.

The current issues with opioids crosses back over to NSAIDs. As physicians embrace the warnings and as regulatory agencies enforce a crackdown aimed at curtailing the opioid epidemic, I would expect to see the NSAID prescription numbers rise as physicians switch from opioids back to perceived safer waters with NSAIDs. What won’t shift is the basic reason for prescribing in the first place — pain control and the lack of awareness and clinical experience of other therapeutic options and how and when to use them. Chiropractic physicians need to ensure prescribers understand our treatment modality benefits and how they fit into treatment algorithms, which endorse those treatments most likely to be effective, while also being the safest starting point in patient care.

Each of us has the ability to make a positive impact simply by reaching out to our local medical community. Don’t let this opportunity pass you by. It’s easier than you think, and the benefits for each independent DC are too meaningful not to try.

References

1) Antman EM, et al. Use of Nonsteroidal Anti-inflammatory Drugs. An Update for Clinicians: A Scientific Statement From the American Heart Association. Circulation. 2007; 115: 1634-1642.

The National Institutes of Health (NIH) gives examples of black box warnings for drugs, including this one for the NSAID Celebrex®:

NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction and stroke, which can be fatal. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.

Dr. Christina Acampora is the founder of Aligned Methods, which offers online medical marketing courses and resources, and is the author of Marketing Chiropractic to Medical Practices, a 2007 Jones and Bartlett publication. She speaks for chiropractic and university organizations and is a consistent contributor for ACA News. She can be reached at www.alignedmethods.com.